Quality of life and its association with anxiety, depression, and clinical factors among patients with metastatic cancer attending oncology centers in Northwest Ethiopia.

Background

Worldwide, cancer remains a leading cause of morbidity and mortality, affecting countries across all levels of development. 1 Based on the most recent globally available data as of 2024, GLOBOCAN projections indicate that the annual number of new cancer cases will climb from 19 million in 2020 to approximately 29 million by 2040. Correspondingly, the global cancer death toll, which stood at nearly 10 million in 2020, is anticipated to escalate to 16 million over the same period. 2 African cancer incidence and mortality are projected to increase more rapidly than in any other global region. The regional burden is expected to approximately double over the coming two decades, with estimated new cases rising from 1.1 million to 2.1 million and cancer-attributable deaths increasing from 711,429 to 1.4 million between 2020 and 2040. 3 Moreover, nations within sub-Saharan Africa, Ethiopia among them, are expected to experience a disproportionately elevated burden in terms of both new diagnoses and cancer-related mortality. In Ethiopia alone, the year 2022 saw an estimated 80,334 incident cancer cases and 54,698 associated deaths. 4

Patients with advanced cancer experience various symptoms resulting from the cancer itself, the outcome of cancer treatment, or an interaction between the two. 5 Despite medical advancements, receiving a cancer diagnosis induces stress in patients and makes them susceptible to experiencing a range of physical, psychosocial, and financial challenges, potentially reducing their Quality of Life (QoL). 6 These challenges arise both from the disease process itself, such as tumor-related pain and cancer-related fatigue, and from its treatment, particularly chemotherapy-induced effects, including nausea, vomiting, and alopecia, as well as radiotherapy- and surgery-related morbidity. Psychological issues like stress, anxiety, and depression further contribute, along with social problems such as social isolation and loss of roles and functions and sociodemographic characteristics like age, marital status, residency, education, and income. Disease and treatment-related factors, including cancer stage and type, site of metastasis, and treatment modality, also play a role. 7 – 9

Depression and anxiety are among the most common psychological conditions experienced by patients with advanced cancer. These disorders often arise from fear of death, progressive loss of functional independence, increasing symptom burden, and disease progression. 10 Depression is particularly prevalent, with reported rates ranging from 3% to 69% among patients with advanced cancer and reaching as high as 77% in those with terminal cancer. 11 Similarly, the prevalence of anxiety varies considerably across studies, with estimates ranging from 29% to 52%. 11 – 13 The occurrence and severity of depression and anxiety are influenced by several factors, including cancer type, older age, inadequate symptom control, limited family support, reduced physical, emotional, and cognitive functioning, and poorer overall QoL. 14

In low-income countries, limited healthcare resources increasingly make cancer a major threat to citizens’ QoL. 15 Over recent decades, QoL has gained growing importance in oncology research and clinical practice. 16 Monitoring symptoms and QoL is vital in advanced cancer care because it increases awareness among health care professionals to better anticipate patients’ changing needs and improves clinical outcomes (i.e., fewer emergency room visits, fewer hospitalizations, a longer duration of palliative chemotherapy, and superior quality-adjusted survival). 17

In Ethiopia, several studies have already been conducted using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire, which assessed the level of QoL in cancer patients (EORTC QoLQ-C30). 18 – 21 However, this study is the first of its kind specifically targeting patients with metastasis and identifying the determinants of QoL for each domain. Gaining insights into the QoL level and the factors influencing it can contribute to raising awareness, fostering policy development in cancer care, and optimizing resource allocation in less-developed nations. Hence, the aim of this study was to assess the QoL and its association with anxiety, depression, and clinical factors among patients with metastatic cancer attending oncology centers in Northwest Ethiopia.

Methods

Study setting, period, and design

A cross-sectional study was carried out from August to October 2023 at the University of Gondar Comprehensive Specialized Hospital (UoGCSH), Felege-Hiwot Comprehensive Specialized Hospital (FHCSH), and Tibebe-Ghion Comprehensive Specialized Hospital (TGCSH).

Population and eligibility criteria

The source population consisted of all cancer patients with metastasis receiving care at oncology centers in Northwest Ethiopia. The study population included all cancer patients with metastasis at UoGCSH, FHCSH, and TGCSH who met the inclusion criteria during the data collection period. Individuals aged 18 years and older with a confirmed cancer metastasis were included in the study. Patients in critical condition who were unable to respond to oral questions and those unwilling to participate in the study were excluded from the study.

Sample size determination

The sample size for this study was determined using a single population proportion formula. To ensure a representative sample, a proportion of 50% was applied in the calculation. n = ( Z α / 2 ) 2 × p ( 1 − p ) w 2 , where n is the desired sample size for a population, Zα/2 is the typical normal distribution set at 1.96 (which corresponds to a 95% CI), P signifies that positive prevalence was utilized in calculating the optimal sample size, and W is the degree of accuracy 0.05 required (a marginal error is 0.05). Then computing for n = 1.96 2* 0.5(1-0.5)/0.05 2 , n = 384. After accounting for a 10% non-response rate, the sample size was adjusted to 422. However, the total population was < 10,000, correction formula was used to calculate the final sample size and yielded 289.7 ∼ 290.

Sampling technique and procedure

A consecutive sampling technique was employed to recruit participants. To enhance representativeness, the final sample size was proportionally allocated based on the number of cancer patients at each hospital from the previous three months’ registration records, which was 925. Accordingly, 118 participants were assigned to FHCSH, 112 to UoGCSH, and 60 to TGCSH. All eligible patients presenting for palliative care during the study period were consecutively enrolled until the required sample size was achieved.

Study variables

The dependent variable was QoL. The predictor variables were the sociodemographic characteristics of the participants (i.e., sex, age, marital status, residence, educational status, and health insurance), clinical and psychological-related variables (i.e., duration of illness, duration of treatment, performance status, comorbidity, depression, anxiety, and social support), and treatment modality.

Data collection instrument, procedures, and quality control

A structured questionnaire, initially derived from existing literature, 18 , 22 , 23 underwent modifications to align with the specific context of the study area and the sociodemographic attributes of the participants. The tools were separately translated into Amharic from their original English counterparts. Independent translators, who were blind to the original versions, back-translated the Amharic version into English after synthesizing the translations. Changes were made based on consensus after a review.

The data collection instrument comprises six sections. The initial segment includes sociodemographic details of the study participants, encompassing age, gender, marital status, place of residence, educational level, occupation, and health insurance coverage. The subsequent section comprises clinical, psychological, and treatment-related variables, including cancer diagnosis type, illness and treatment duration, performance status, comorbidity, depression, anxiety, social support, and treatment modalities.

The third segment involved the assessment of QoL using the World Health Organization Quality of Life (WHOQoL–BREF), a 26-item self-administered questionnaire. This tool is widely recognized for its cross-cultural validity and reliability in evaluating QoL, demonstrated through its four domains: physical, psychological, social, and environmental. 24 It generates domain scores across four categories: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), along with two individually scored items regarding individuals’ perceptions of their QoL (Q1) and overall health (Q2). Scores from items within each domain are aggregated, and either the mean or median is computed to determine the domain score. 25 The WHOQoL–BREF has been previously utilized in Ethiopia. 22

The fourth part of the questionnaire evaluates social support using the Oslo Social Support Scale-3 (OSSS-3). Scores on the scale range from 3 to 14, with interpretations as follows: a score of 3 to 8 indicates poor social support, 9 to 11 suggests moderate social support, and 12 to 14 signifies strong social support. 26

The fifth segment involved assessing depression using the Patient Health Questionnaire-9 (PHQ-9). Scores on the PHQ-9 scale range from 0 to 27, with each of the nine items scored from 0 (not at all) to 3 (nearly every day). Interpretations of the scores are as follows: a score of 0-4 indicates minimal or no depression; 5-9 suggests mild depression; 10–14 indicates moderate depression; 15–19 suggests moderately severe depression; and a score of 20–27 indicates severe depression. 27 Additionally, the PHQ-9 has been validated within the Ethiopian healthcare context, demonstrating a specificity and sensitivity of 67% and 86%, respectively. A cut-off point of 10 or more is utilized to screen for depression. 28

The sixth part of the questionnaire evaluated anxiety using the Generalized Anxiety Disorder-7 (GAD-7). Response categories such as “not at all,” “several days,” “more than half the days,” and “nearly every day” were assigned scores of 0, 1, 2, and 3, respectively, for the seven questions, and the scores were summed. With a threshold score of 10, GAD-7 demonstrates a sensitivity of 89% and specificity of 82% for GAD. 29

Data collection was conducted through face-to-face interviews using a pretested, structured questionnaire. At UoGCSH and FHCSH, three nurses with bachelor’s degrees carried out the interviews under the guidance of a senior oncology nurse with a master’s degree. Similarly, at TGCSH, two nurses with bachelor’s degrees conducted the interviews under the supervision of a senior oncology nurse with a bachelor’s degree. Supervisors ensured that data collectors were equipped with necessary materials each day and reviewed completed questionnaires for accuracy, promptly addressing any concerns. The lead researcher provided resources across all study sites.

To maintain data quality, the principal investigator organized one-day training sessions for data collectors and supervisors at each study site. A pretest involving 22 cancer patients (5% of the total sample) was conducted at Dessie Comprehensive Specialized Hospital’s oncology center to identify potential issues with the data collection tool and ensure questionnaire consistency. Based on the pretest results, adjustments were made, including correcting typing errors and reorganizing questionnaire sections. The internal consistency of the WHOQoL–BREF tool was evaluated, producing acceptable Cronbach’s alpha values of 0.823 for physical health, 0.802 for psychological health, 0.83 for social relationships, and 0.794 for environmental health.

Operational definitions

Anxiety : Individuals who attain a score of 10 or higher on the GAD-7 scale were identified as having anxiety. 29

Depression : Individuals scoring 10 or higher on the PHQ-9 scale were classified as having depression. 28

Quality of life : Scores nearing 100 on the WHOQOL-BREF 26 items indicate the highest achievable QoL, while scores nearing zero indicate the lowest QoL. 30

Social support : As per the OSSS-3, individuals scoring between 3 and 8 are categorized as having inadequate social support, those scoring 9–11 are classified as having moderate social support, and those scoring 12–14 are deemed to have strong social support. 26

Performance status : Patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) grades of 0 and 1 are classified as having favorable good status, while grades of ECOG PS 2, 3, and 4 are indicative of poor performance status. 31

Data entry and analysis

The Statistical Package for Social Sciences (SPSS) version 26 was used for analysis after the gathered data was cleaned, coded, and entered into EpiData 4.6.0. To evaluate the distribution of data, descriptive analysis employed metrics including frequency, percentages, and mean with standard deviation (SD). The predictors for each domain and overall QoL were identified using multiple linear regression models.

Scatter plots were used to confirm linearity and show that QoL and all continuous independent variables were negatively correlated. Histograms and normal probability-probability (P-P) plots were used to confirm the normality assumption, showing a normal distribution with skewness ranging between ±1, which is indicative of normality. Independent observations were supported by the Durbin-Watson statistic, which varied between 1.5 and 2.5. When multicollinearity was evaluated, the highest Variance Inflation Factor (VIF) was less than 5, which is considered acceptable.

For multiple linear regressions, variables having a p-value < 0.25 in simple linear regression were selected. Unstandardized beta coefficients, along with a 95% Confidence Interval (CI), were employed to evaluate the strength of the association and statistical significance in the multiple linear regression analysis. A p-value < 0.05 was considered indicative of an independently associated factor.

Ethics approval and consent to participate

The study was granted ethical approval by the Institutional Review Board of the College of Medicine and Health Sciences at Bahir Dar University (reference number 796/2023). Prior to participation, all participants were thoroughly informed about the study’s objectives and provided written informed consent, both for participation and for potential publication in academic journals. Measures were implemented to protect participants’ privacy, and personal identifiers were removed from the collected data. The study followed the ethical principles outlined in the Declaration of Helsinki.

Results

Sociodemographic characteristics among cancer patient with metastasis

This study involved 290 participants, with females comprising the majority (64.8%), and more than one-third (36.3%) of them were above 60 years of age. A significant portion of the participants were married (80.3%) and lived in urban areas (61.7%). Around one-fourth (26.9%) of respondents had completed secondary school, and one-fifth (20.0%) of them were employed privately. The majority (72.4%) of participants had health insurance ( Table 1 ). Table 1. Sociodemographic characteristics among cancer patients with metastasis (n = 290). Variables Categories Frequency (%) Sex Male 102 (35.2) Female 188 (64.8) Age 18-40 23 (7.9) 41-49 65 (22.4) 50-59 97 (33.4) >60 105 (36.3) Marital status Married 233 (80.3) Unmarried 57 (19.7) Residence Urban 179 (61.7) Rural 111 (38.3) Educational level No formal education 54 (18.6) Primary (1–8 grades) 68 (23.4) Secondary (9–12 grade) 78 (26.9) Diploma and above 90 (31.1) Occupation Government employee 47 (16.2) Farmer 51 (17.6) Private employee 58 (20.0) Retired 27 (9.3) Housewife 107 (36.9) Health insurance Yes 210 (72.4) No 80 (27.6)

Clinical, psychological, and treatment-related characteristics among cancer patients with metastasis

Close to one-third (29.7%) of participants had breast cancer origins, and the majority (59.7%) of them have been living with the disease for between one and five years. The majority (67.2%) of participants had received treatment in the range of one to five years, and 80.7% of them had poor performance status. More than two-thirds (71.0%) of patients had comorbid illness, and 57.2% had poor social support. The majority (60.3%) of patients were screened for anxiety, and 73.1% of them reported experiencing depression. More than one-third (37.6%) of respondents had taken chemotherapy and surgery ( Table 2 ). Table 2. Clinical, psychological, and treatment-related characteristics among cancer patients with metastasis (n = 290). Variables Categories Frequency (%) Origin of cancer Breast 86 (29.7) Cervical 68 (23.4) Colorectal 38 (13.1) Ovarian 27 (9.3) Lymphoma 18 (6.2) Bone and soft tissue 17 (5.9) Lung 13 (4.4) Other * 23 (8.0) Duration of the illness < 1 year 60 (20.7) 1-5 year 173 (59.7) >5 year 57 (19.6) Duration of treatment < 1 year 51 (17.6) 1-5 year 195 (67.2) >5 year 44 (15.2) Performance status Good 56 (19.3) Poor 234 (80.7) Presence of comorbidity Yes 206 (71.0) No 84 (29.0) Social support Poor 166 (57.2) Moderate 73 (25.2) Strong 51 (17.6) Anxiety Yes 175 (60.3) No 115 (39.7) Depression Yes 212 (73.1) No 78 (26.9) Treatment modality Chemotherapy 181 (62.4) Chemotherapy and surgery 109 (37.6) * Head and neck, Hodking lymphoma, Pancreatic cancer, Squamous cell carcinoma, Multiple myeloma, Hepatocellular carcinoma.

Quality of life among cancer patients with metastasis

In this study, the mean score for the overall QoL among cancer patients was 31.17 (95% CI: 30.47, 31.95), with an SD of 6.51. Among the four QoL domains, participants scored the lowest in physical health (26.74±10.09) and the highest in environmental health (37.64±14.06) ( Table 3 ). Table 3. Quality of life among cancer patients with metastasis (n = 290). Domains Mean ± SD 95% CI Physical health 26.74±10.09 (25.63, 27.95) Psychological health 30.46±12.03 (29.14, 31.92) Social relationship 34.48±13.97 (32.93, 36.12) Environmental health 37.64±14.06 (36.09, 39.26) Overall QoL 31.17±6.51 ( 30.47, 31.95 )

Predictors of quality of life among cancer patients with metastasis

Certain variables were found to have a significant association across the QoL domains after running multiple linear regression analysis. QoL in physical health was negatively associated with poor performance status (β = -4.04; 95% CI: -6.88, -1.19), presence of comorbid illness (β = -4.17; 95% CI: -6.58, -1.63), depression (β = -3.01; 95% CI: -5.46, -0.56), anxiety (β = -3.11; 95% CI: -5.35, -0.87), and poor social support (β = -3.94; 95% CI: -6.85, -1.03) ( Table 4 ). QoL in psychological health was negatively associated with poor performance status (β = -5.27; 95% CI: -8.77, -1.77), depression (β = -4.41; 95% CI: -7.40, -1.41), anxiety (β = -4.59; 95% CI: -7.29, -1.90), and poor social support (β =-3.84; 95% CI: -7.49, -0.19) ( Table 5 ). The social relationship domain of QoL had a negative significant association with depression (β = -3.70; 95% CI: -7.36, -0.40) and anxiety (β = -3.85; 95% CI: -7.14, -0.56) ( Table 6 ). The environmental domain of QoL had a significant negative association with poor performance status (β = -4.38; 95% CI: -8.47, -0.28), depression (β = -3.82; 95% CI: -7.41, -0.23), and anxiety (β = -3.69; 95% CI: -7.01, -0.38) ( Table 7 ). The overall QoL had a negative significant association with poor performance status (β = -2.52; 95% CI: -4.35, -0.69), presence of comorbidity (β = -2.46; 95% CI: -4.03, -0.90), depression (β = -3.17; 95% CI: -4.76, -1.59), anxiety (β = -1.99; 95% CI: -3.38, -0.47), and poor social support (β = -2.52; 95% CI: -4.43, -0.61) ( Table 8 ). Table 4. Multivariate linear regression analysis for the physical health domain and its predictors among cancer patients with metastasis (n = 290). Variables Categories SLR: β (95%CI) MLR: β (95%CI) P-value Sex Male -1.78 (-4.22, 0.65) -1.35 (-3.69, 0.98) 0.256 Female Ref Ref ​ Age ≥60 0.37 (-4.18, 4.92) 0.70 (-4.13, 4.29) 0.872 50-59 -0.16 (-4.60, 4.57) 0.90 (-4.28, 4.82 0.989 40-49 -2.89 (-7.71, 1.91) -2.13 (-6.65, 2.37 0.352 18-39 Ref Ref ​ Marital status Unmarried -1.77 (-4.71, 1.15) -1.56 (-4.39, 1.26) 0.276 Married Ref Ref ​ Residence Urban -1.75 (-4.15, 0.63) -1.12 (-3.36, 1.12) 0.326 Rural Ref Ref ​ Educational status No formal education -2.35 (-5.78, 1.06) -1.29 (-4.49, 1.90) 0.427 Primary school -2.26 (-5.45, 0.92) -1.44 (-4.44, 1.55) 0.345 Secondary school -1.22 (-4.29, 1.85) 0.31 (-2.61, 3.23) 0.835 College and above Ref Ref ​ Health insurance No -1.96 (-4.56, 0.64) -1.50 (-3.95, 0.94) 0.228 Yes Ref Ref ​ Duration of illness >5 year -0.36 (-3.98, 3.35) -0.41 (-3.82, 2.99) 0.812 1-5 year -2.01 (-4.97, 0.97) -2.61 (-5.39, 0.17) 0.066 < 1 year Ref Ref ​ Duration of treatment >5 year 2.29 (-1.78, 6.37) 2.02 (-1.78, 5.83) 0.295 1-5 year -1.93 (-5.05, 1.19) -1.29 (-4.25, 1.65) 0.388 < 1 year Ref Ref ​ Performance status Poor -5.43 (-8.36, -2.54) -4.04 (-6.88, -1.19) 0.006 Good Ref Ref ​ Presence of comorbidity Yes -5.35 (-7.85, -2.85) -4.17 (-6.58, -1.63) 0.001 No Ref Ref ​ Depression Yes -3.33 (-5.92, - 0.75) -3.01 (-5.46, -0.56) 0.016 No Ref Ref ​ Anxiety Yes -4.05 (-6.41, -1.71) -3.11 (-5.35, -0.87) 0.007 No Ref Ref ​ Social support Poor -4.69 (-7.75, -1.62) -3.94 (-6.85, -1.03) 0.008 Moderate 0.88 (-3.39, 3.56) -0.90 (-3.34, 3.03) 0.991 Strong Ref Ref ​ Treatment modality Chemotherapy and surgery -1.92 (-4.33, 0.47) -0.56 (-2.86, 1.74) 0.632 Chemotherapy Ref Ref ​ R = 0.591, R 2 = 0.431, and adjusted R 2 = 0.327. ß, unstandardized beta coefficient; SLR, Simple Linear Regression; MLR, Multiple Linear Regression. Bold figures indicate statistically significant variables. Table 5. Multivariate linear regression analysis for the psychological health domain and its predictors among cancer patients with metastasis (n = 290). Variables Categories SLR: β (95%CI) MLR: β (95%CI) P-value Sex Male -1.89 (-4.80, 1.02) -1.62 (-4.49, 1.25) 0.267 Female Ref Ref ​ Age ≥60 2.72 (-2.73, 8.19) 0.29 (-4.92, 5.52) 0.911 50-59 2.56 (-2.93, 8.06) 1.27 (-3.99, 6.54) 0.634 40-49 4.03 (-1.45, 10.05) 2.61 (-2.89, 8.12) 0.350 18-39 Ref Ref ​ Marital status Unmarried -2.75 (-6.25, 0.73) -3.29 (-6.69, 0.11) 0.060 Married Ref Ref ​ Residence Urban -2.15 (-5.01, 0.70) -0.37 (-3.18, 2.43) 0.792 Rural Ref Ref ​ Educational status No formal education -0.80 (-4.88, 3.28) -0.62 (-4.51, 3.27) 0.753 Primary school 0.18 (-3.70, 3.92) -0.33 (-4.07, 3.33) 0.857 Secondary school -2.45 (-6.12, 1.22) -1.36 (-4.95, 2.21) 0.453 College and above Ref Ref ​ Health insurance No 2.05 (-1.05, 5.16) 2.90 (-0.15, 5.92) 0.060 Yes Ref Ref ​ Duration of illness >5 year -3.47 (-7.84, 0.91) -2.57 (-6.78, 1.63) 0.229 1-5 year -0.37 (-3.91, 3.17) -0.25 (-3.64, 3.21) 0.902 < 1 year Ref Ref ​ Duration of treatment >5 year 1.28 (-3.56, 6.13) 0.75 (-4.01, 5.51) 0.755 1-5 year 3.92 (0.22, 7.63) 3.24 (-0.39, 6.89) 0.080 < 1 year Ref Ref ​ Performance status Poor -6.79 (-10.23, -3.25) -5.27 (-8.77, -1.77) 0.003 Good Ref Ref ​ Presence of comorbidity Yes -1.93 (-4.99, 1.13) -1.43 (-4.39, 1.52) 0.341 No Ref Ref ​ Depression Yes -5.50 (-8.58, -2.42) -4.41 (-7.40, -1.41) 0.004 No Ref Ref ​ Anxiety Yes -4.17 (-6.98, -1.36) -4.59 (-7.29, -1.90) 0.001 No Ref Ref ​ Social support Poor -5.57 (-9.25, -1.88) -3.84 (-7.49, -0.19) 0.039 Moderate -0.47 (-4.70, 374) -0.94 (-5.05, 3.17) 0. 653 Strong Ref Ref ​ Treatment modality Chemotherapy and surgery -2.06 (-4.93, 0.80) -0.82 (-3.64, 1.99) 0.566 Chemotherapy Ref Ref ​ R = 0.571, R 2 = 0.416, and adjusted R 2 = 0.301. ß, unstandardized beta coefficient; SLR, Simple Linear Regression; MLR, Multiple Linear Regression. Bold figures indicate statistically significant variables. Table 6. Multivariate linear regression analysis for the social relationship domain and its predictors among cancer patients with metastasis (n = 290). Variables Categories SLR: β (95%CI) MLR: β (95%CI) P-value Sex Male -2.43 (-5.81, 0.94) -1.53 (-4.98, 1.92) 0.383 Female Ref Ref ​ Age ≥60 -1.41 (-7.86, 5.03) -3.19 (-9.65, 3.27) 0.332 50-59 -4.15 (-10.65, 2.33) -5.30 (-11.87, 1.26) 0.113 40-49 -3.86 (-10.63, 2.90) -5.15 (-11.97, 1.67) 0.138 18-39 Ref Ref ​ Marital status Unmarried -2.46 (-6.52, 1.59) -1.53 (-5.68, 2.61) 0.467 Married Ref Ref ​ Residence Urban 2.41 (-0.91, 5.73) 2.06 (-1.28, 5.41) 0.227 Rural Ref Ref ​ Educational status No formal education 1.97 (-2.75, 6.71) 1.43 (-3.31, 6.18) 0.552 Primary school 3.87 (-0.54, 8.29) 3.26 (-1.22, 7.74) 0.154 Secondary school 0.91 (-3.33, 5.17) 0.33 (-3.99, 4.67) 0.878 College and above Ref Ref ​ Health insurance No -2.62 (-6.23, 0.98) -2.45 (-6.12, 1.22) 0.190 Yes Ref Ref ​ Duration of illness >5 year 4.11 (-0.95, 9.19) 3.11 (-2.05, 8.28) 0.237 1-5 year 3.15 (-0.59, 7.62) 2.43 (-1.76, 6.63) 0.254 < 1 year Ref Ref ​ Duration of treatment >5 year 3.51 (-2.14, 9.16) 1.43 (-4.35, 7.23) 0.835 1-5 year -0.53 (-4.27, 4.03) -0.46 (-4.85, 3.92) 0.626 < 1 year Ref Ref ​ Performance status Poor -2.66 (-6.75, 1.41) -2.96 (-7.04, 1.11) 0.154 Good Ref Ref ​ Presence of comorbidity Yes -2.17 (-5.73, 1.38) -1.72 (-5.38, 1.93) 0.355 No Ref Ref ​ Depression Yes -3.38 (-7.01, 0.24) -3.70 (-7.36, -0.40) 0.047 No Ref Ref ​ Anxiety Yes -3.72 (-7.00, -0.48) -3.85 (-7.14, -0.56) 0.022 No Ref Ref ​ Social support Poor -1.21 (-5.59, 3.17) -1.07 (-5.49, 3.34) 0.633 Moderate 3.14 (-1.85, 8.13) 2.91 (-2.10, 7.93) 0.254 Strong Ref Ref ​ Treatment modality Chemotherapy and surgery 2.33 (-0.99, 5.66) 3.00 (-0.35, 6.36) 0.080 Chemotherapy Ref Ref ​ R = 0.518, R 2 = 0.361, and adjusted R 2 = 0.249. ß, unstandardized beta coefficient; SLR, Simple Linear Regression; MLR, Multiple Linear Regression. Bold figures indicate statistically significant variables. Table 7. Multivariate linear regression analysis for the environmental health domain and its predictors among cancer patients with metastasis (n = 290). Variables Categories SLR: β (95%CI) MLR: β (95%CI) P-value Sex Male -2.53 (-5.93, 0.85) -2.26 (-5.65, 1.13) 0.191 Female Ref Ref ​ Age ≥60 -2.10 (-8.47, 4.26) -3.47 (-9.68, 2.73) 0.272 50-59 -1.43 (-7.84, 4.98) -2.75 (-9.04, 3.52) 0.389 40-49 -4.96 (-11.68, 1.74) -6.29 (-12.91, 0.32) 0.062 18-39 Ref Ref ​ Marital status Unmarried -3.35 (-7.43, 0.72) -3.62 (-7.76, 0.52) 0.086 Married Ref Ref ​ Residence Urban -2.41 (-5.75, 0.92) -2.28 (-5.62, 1.04) 0.177 Rural Ref Ref ​ Educational status No formal education -3.19 (-7.96, 1.57) -3.44 (-8.12, 1.24) 0.150 Primary school -0.29 (-4.74, 4.16) 0.85 (-3.59, 5.30) 0.706 Secondary school 0.71 (-4.21, 4.35) 1.32 (-2.95, 5.59) 0.543 College and above Ref Ref ​ Health insurance No -2.85 (-6.48, 0.76) -1.97 (-5.55, 1.60) 0.279 Yes Ref Ref ​ Duration of illness >5 year -3.11 (-8.21, 1.97) -2.82 (-7.91, 2.26) 0.276 1-5 year 1.43 (-2.69, 5.56) 0.80 (-3.34, 4.95) 0.703 < 1 year Ref Ref ​ Duration of treatment >5 year 2.08 (-3.61, 7.76) 0.20 (-5.54, 5.94) 0.945 1-5 year 3.55 (-0.79, 7.89) 3.59 (-0.74, 7.93) 0.104 < 1 year Ref Ref ​ Performance status Poor -4.15 (-8.25, -0.62) -4.38 (-8.47, -0.28) 0.036 Good Ref Ref ​ Presence of comorbidity Yes -2.54 (-6.12, 1.03) -2.97 (-6.61, 0.66) 0.108 No Ref Ref ​ Depression Yes -3.59 (-7.23, 0.58) -3.82 (-7.41, -0.23) 0.037 No Ref Ref ​ Anxiety Yes -5.48 (-8.75, -2.22) -3.69 (-7.01, -0.38) 0.029 No Ref Ref ​ Social support Poor -2.72 (-7.14, 1.68) -2.09 (-6.37, 2.33) 0.362 Moderate 0.97 (-4.06, 6.03) 0.90 (-4.84, 5.02) 0.972 Strong Ref Ref ​ Treatment modality Chemotherapy and surgery -2.32 (-5.67, 1.02) -1.70 (-5.05, 1.65) 0.319 Chemotherapy Ref Ref ​ R = 0.582, R 2 = 0.388, and adjusted R 2 = 0.298. ß, unstandardized beta coefficient; SLR, Simple Linear Regression; MLR, Multiple Linear Regression. Bold figures indicate statistically significant variables. Table 8. Multivariate linear regression analysis for the overall quality of life and its predictors among cancer patients with metastasis (n = 290). Variables Categories SLR: β (95%CI) MLR: β (95%CI) P-value Sex Male -1.06 (-2.63, 0.51) -0.48 (-2.00, 1.03) 0.532 Female Ref Ref ​ Age ≥60 -1.60 (-4.56, 1.35) -1.93 (-4.66, 0.79) 0.163 50-59 -1.76 (-4.74, 1.22) -1.55 (-4.33, 1.22) 0.273 40-49 -2.08 (-5.19, 1.03) -2.34 (-5.26, 0.57) 0.115 18-39 Ref Ref ​ Marital status Unmarried -1.48 (-3.37, 0.41) -1.37 (-3.20, 0.46) 0.144 Married Ref Ref ​ Residence Urban -1.17 (-2.76, 0.36) -0.73 (-2.19, 0.72) 0.323 Rural Ref Ref ​ Educational status No formal education -1.53 (-3.74, 0.66) -1.33 (-3.41, 0.75) 0.209 Primary school -1.21 (-3.26, 0.85) -0.58 (-2.55, 1.38) 0.558 Secondary school 0.35 (-1.63, 2.33) 0.98 (-0.89, 2.87) 0.304 College and above Ref Ref ​ Health insurance No -1.31 (-2.98, 0.36) -0.36 (-1.93, 1.21) 0.653 Yes Ref Ref ​ Duration of illness >5 year 1.51 (-0.85, 3.87) 1.13 (-1.11, 3.32) 0.329 1-5 year -0.45 (-2.36, 1.46) -0.38 (-2.27, 1.44) 0.680 < 1 year Ref Ref ​ Duration of treatment >5 year 0.19 (-2.53, 2.73) 0.27 (-2.21, 2.77) 0.827 1-5 year 1.38 (-0.62, 3.40) 1.24 (-0.64, 3.13) 0.197 < 1 year Ref Ref ​ Performance status Poor -3.47 (-5.33, -1.60) -2.52 (-4.35, -0.69) 0.007 Good Ref Ref ​ Presence of comorbidity Yes -2.69 (-4.33, -1.05) -2.46 (-4.03, -0.90) 0.002 No Ref Ref ​ Depression Yes -3.59 (-5.23, -1.96) -3.17 (-4.76, -1.59) <0.001 No Ref Ref ​ Anxiety Yes -2.85 (-4.36, -1.34) -1.99 (-3.38, -0.47) 0.009 No Ref Ref ​ Social support Poor -2.87 (-4.90, -0.85) -2.52 (-4.43, -0.61) 0.010 Moderate -0.81 (-3.12, 1.49) -0.79 (-2.99, 1.40) 0.476 Strong Ref Ref ​ Treatment modality Chemotherapy and surgery -1.21 (-2.76, 0.34) -0.75 (-2.21, 0.71) 0.314 Chemotherapy Ref Ref ​ R = 0.672, R 2 = 0.462, and adjusted R 2 = 0.384. ß, unstandardized beta coefficient; SLR, Simple Linear Regression; MLR, Multiple Linear Regression. Bold figures indicate statistically significant variables.

Discussion

Despite advancements in medical treatment, a cancer diagnosis often instigates significant stress for the patient and can lead to the emergence of various physical, psychosocial, and financial challenges. These challenges may ultimately diminish the individual’s overall QoL. 6 The purpose of this study was to assess the QoL and its association with anxiety, depression, and clinical factors among patients with metastatic cancer attending oncology centers in Northwest Ethiopia. The overall mean QoL score was 31.17 with an SD of 6.51, and the domain with the lowest mean score was physical health (26.74±10.09). Poor performance status, the presence of comorbidity, depression, anxiety, and poor social support were the predictors of overall QoL.

Consistent with previous studies, 32 – 35 this study showed that physical health had the lowest mean score of the WHOQoL BREF assessment tool. In contrast, a study from Ethiopia 22 and Nigeria 36 indicated that the lowest mean score was on social relationship and environmental health domains, respectively. This difference could stem from methodological variations, including discrepancies in study population, in which the current study included only those patients with metastasis, while the studies from Ethiopia and Nigeria included only breast cancer patients. This highlights the critical gap in palliative care and physical symptom management with direct implications for designing stage-specific interventions so as to improve physical health.

Patients with poor performance status had reduced QoL in the physical, psychological, and environmental domains and overall QoL, which is supported by previous evidence. 37 This might stem from the challenges faced by patients with poor performance status, such as difficulty in performing daily activities, increased fatigue, and diminished overall well-being, all of which could impact their QoL. Therefore, providing low-intensity physical rehabilitation and nutritional support will enhance and maintain the level of performance status.

Patients with comorbid illness experienced a decline in QoL, particularly in the physical and overall QoL. This observation aligned with findings from studies conducted in Kenya, 38 Nigeria, 39 and Serbia. 40 The presence of comorbidity could lead to adverse outcomes in conjunction with cancer treatment. These treatments might negatively impact other existing health conditions, thereby further affecting the QoL of these patients. 41 Thus, patients with comorbid illness need to have improved quality of care.

Patients exhibiting symptoms of depression and anxiety had reduced QoL in all domains and overall QoL. This finding agrees with previous studies. 42 – 48 Findings of this and previous studies indicated that depression and anxiety are important psychological comorbidities of cancer patients, which significantly alter the QoL of these patients. 49 Educating healthcare teams about the psychological effects of cancer can improve patient care and subsequently enhance QoL. Close relationships with healthcare teams, characterized by spending more time with cancer patients, have been shown to contribute to psychological improvements for these patients. 50

Relating to social support, patients who received poor social support had low QoL in the physical, psychological, and overall domains. This finding agrees with a study from China. 37 Unfulfilled social needs can diminish the QoL for patients, even when they are receiving treatment in hospitals. Empirical evidence suggests that social support serves as a buffer against the negative effects of stress, helps protect against physical and mental health problems, and facilitates psychological adjustment to chronic medical conditions such as cancer. 51 , 52 Integration of supportive care through the treatment course is necessary. In addition, strengthening family and caregiver engagement is mandatory so as to enhance QoL.

The findings of this study carry several implications for clinical practice and future research. The strong association between poor performance status, comorbidity, and reduced physical QoL indicates the need for integrating palliative care and symptom management in the treatment pathway. In addition, the high prevalence of anxiety and depression as a significant factor of QoL indicates the need for routine psychological screening and the integration of psychiatric services within the oncology clinic. Besides social support, health care professionals should evaluate the patients’ social engagement and involve family members and care providers in planning to ensure a strong support system is in place. This study reveals a critical gap in the literature, as most previous published studies focused on cancer patients as a general or on specific cancer types rather than on the population of patients with metastasis.

Strengths and limitations of the study

This study is the first of its kind in Ethiopia to assess the QoL of cancer patients with metastasis and to identify the determinants of each QoL domain. The multicenter study setting increases the generalizability. Nevertheless, the WHOQoL–BREF assessment tool was not validated in cancer patients. Besides, findings in this study were based on participant self-reporting, which could introduce recall bias and rely on respondents’ honesty levels. Furthermore, due to its cross-sectional design, the study could not establish causal relationships between the outcome and the independent variables.

Conclusion and recommendation

This study concluded that the physical health domain of QoL among cancer patients with metastasis had the lowest mean score. Poor performance status, the presence of comorbidity, depression, anxiety, and poor social support were the predictors of overall QoL. This study recommends that healthcare professionals and other stakeholders should prioritize interventions that improve physical health and performance status. Prioritizing initiatives to strengthen social support is also crucial. For patients with anxiety and depression to effectively manage these symptoms, proper clinical assessment and follow-up are crucial. Future research could further investigate the causal relationship between QoL and various potential predictor variables.

Acknowledgments

The authors acknowledge Bahir Dar University and the study participants.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ORCID iD

Fasil Bayafers Tamene https://orcid.org/0009-0005-3026-6584

Ethical considerations

The study was granted ethical approval by the Institutional Review Board of the College of Medicine and Health Sciences at Bahir Dar University (reference number 796/2023).

Consent to participate

Prior to participation, all participants were thoroughly informed about the study’s objectives and provided written informed consent, both for participation and for potential publication in academic journals. Measures were implemented to protect participants’ privacy, and personal identifiers were removed from the collected data. The study followed the ethical principles outlined in the Declaration of Helsinki.

Data Availability Statement

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. *

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List of abbreviations

Eastern Cooperative Oncology Group Performance Status

European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire

Felege-Hiwot Comprehensive Specialized Hospital

Generalized Anxiety Disorder 7-item scale

Oslo Social Support Scale 3-item

Patient Health Questionnaire 9-item

Quality of Life

Tibebe-Ghion Comprehensive Specialized Hospital

University of Gondar Comprehensive Specialized Hospital

World Health Organization

World Health Organization Quality of Life.